Alaska Medicaid
Behavioral Health Services
Participant Handbook
July 1, 2021
BH3459_062021 United Behavioral Health operating under the brand Optum Table of Contents About This Handbook ...... 1 Participant Helpline ...... 1 Other Languages ...... 1 How Alaska Medicaid Works ...... 2 Eligibility ...... 2 Medicaid Card/Coupon ...... 2 Field Benefit Issuance ...... 2 Denali KidCare Card ...... 2 CAMA Card/Coupon ...... 2 Care Management Program Card/Coupon...... 2 How to Use Your Alaska Medicaid Card/Coupon ...... 3 Other Medical Insurance or Health Coverage ...... 3 The Alaska Health Insurance Premium Payment Program ...... 4 Who is Covered by Alaska Medicaid? ...... 4 Medicaid Expansion ...... 4 Family Medicaid ...... 4 Denali KidCare ...... 4 Breast and Cervical Cancer Program ...... 5 Long-Term Care ...... 5 Home and Community-Based Waiver Services ...... 5 TEFRA (Disabled Children at Home) ...... 5 Adult Public Assistance Related Medicaid ...... 5 Under 21 Medicaid ...... 6 Medicaid Behavioral Health Services ...... 6 Community Behavioral Health Services ...... 6 Autism Services ...... 6 Mental Health Physician Clinic Services ...... 6 1115 Waiver Mental Health Services ...... 6 1115 Waiver Substance Use Disorder (SUD) Services ...... 6 How to get Behavioral Health Services ...... 7 Mental Health or Substance Use Disorder Services ...... 7 Emergency Services ...... 7 Inpatient Psychiatric Hospital and Residential Psychiatric Treatment Services ...... 7 Travel for Non-Emergency Services ...... 8 Medicaid Participant Rights and Responsibilities ...... 8 Rights as a Patient ...... 8 Responsibilities as a Patient ...... 8 Managing Your Care and How Medicaid Billing Works ...... 8
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Proof of Eligibility ...... 8 Your Copayment ...... 9 If You Receive a Bill ...... 9 If You Receive a Payment For Services Paid by Medicaid ...... 9 Retroactive or Backdated Eligibility ...... 10 Service Authorization ...... 10 Medicaid Renewal Information ...... 10 How You Could Lose Your Medicaid Eligibility ...... 10 Fraud, Waste and Abuse ...... 11 Fraud...... 11 Waste ...... 11 Abuse ...... 11 Complaints ...... 11 How do I File a Complaint? ...... 11 Adverse Benefit Determinations ...... 12 Fair Hearings ...... 12 What is a Fair Hearing? ...... 12 How to Request a Fair Hearing ...... 12 Privacy and Confidentiality ...... 12 How to Find a Provider ...... 13 Medicaid Eligibility Codes and Coverage Categories ...... 14 Helpful Websites and Phone Numbers ...... 15 Public Assistance District and Field Offices ...... 18
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About This Handbook
Updates to this handbook will be needed from time to time as federal and state regulations change. As updates are made, the date of the handbook will also be updated.
Participant Helpline If you are a participant or a participant advocate and have questions about Medicaid coverage, please call 800.225.8764, toll-free statewide Monday through Friday between 8:00 a.m. and 6:00 p.m., Alaska Time. After hours, please leave a message and your call will be returned the following business day. You can also visit our website at https://alaska.optum.com/.
You may also email the helpline staff at [email protected]. The participant services representative will assist you with your questions about services covered by Alaska Medicaid, provide a list of Medicaid-enrolled providers, and explain how to use your Medicaid benefits in general. Most problems are solved with the initial call or with a call back. Some problems take longer to investigate and will need more time.
If you are deaf or hard of hearing and would like to contact us, please call 711 for TTY services. If you would like this handbook in large print, compact disc (cd) or written in another language call 800.225.8764
Other Languages Free language assistance services are available to you. For help, call 800.225.8764.
Chinese: 您有權利免費以您的語言得到幫助和訊息。如需洽詢一位口譯員，請撥電話 800.225.8764.
Hmong: Muaj kev pab txhais lus pub dawb rau koj. Thov hu rau 800.225.8764 lossis saib hauv qab.
Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800.225.8764 번으로전화해 주십시오.
Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800.225.8764.
Spanish ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800.225.8764.
Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 800.225.8764.
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How Alaska Medicaid Works
Eligibility The Division of Public Assistance (DPA) decides initial and ongoing eligibility of individuals and families who may need Medicaid, Denali KidCare, or Chronic and Acute Medical Assistance (CAMA) benefits. DPA staff will assess each person who applies and identify the Medicaid program that meets his or her needs. DPA staff decide eligibility and authorize benefits for all children and adults except those children served by or in the custody of the Office of Children’s Services.
As families change from welfare to work, DPA staff members make sure that eligible family members continue to receive transitional Medicaid benefits. When you become eligible for Medicaid you will receive your own identification (ID) number. DPA sends out written documentation that a participant is eligible for Medicaid coverage in a given month. Any of the following documents will serve as proof of your Medicaid eligibility.
Medicaid Card/Coupon Most Medicaid participants will receive an identification (ID) card. This ID card contains the name, participant ID number, date of birth, eligibility month and year, and eligibility code.
A non-standard participant ID card has the same participant and medical resource information as the standard card but is used for a participant whose Medicaid coverage is restricted to certain services, such as an exam for disability, or emergency care for an alien.
Field Benefit Issuance Once Medicaid coverage has been authorized, a Field Benefit Issuance can be printed at any DPA office. A Field Benefit Issuance contains similar participant and medical resource information as a standard system issued Denali Care or Denali KidCare ID card. A Field Benefit Issuance is provided when the Denali Care or Denali KidCare card is needed immediately and the participant cannot wait for mail delivery.
Denali KidCare Card Each child enrolled in Denali KidCare (DKC) will receive a DKC card. This card can be used for health care and medical-related services only for the person named on the card. The coverage period is generally one year and is good for the period shown on the front of the card.
CAMA Card/Coupon Each CAMA coupon is issued on a monthly basis and is good only for those services covered by the CAMA program and provided by an enrolled provider. The CAMA coupon verifies a participant’s eligibility and lets the provider know what services the participant is can receive.
Care Management Program Card/Coupon The Care Management Program (CMP) Coupon is printed on a full-size sheet of bright pink paper, with the word “RESTRICTED” and is issued on a monthly basis. Unlike other cards and coupons, CMP coupons are issued by the Care Management Program and not by DPA. A coupon contains the participant’s name and other identifying information, as well as the primary provider and pharmacy that have been selected for the participant. When a 2
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participant needs another coupon issued or has questions regarding the program, they may contact the Care Management Program at 907.644.6842. CMP specialist are available to assist Monday through Friday between 8:00 a.m. and 5:00 p.m..
How to Use Your Alaska Medicaid Card/Coupon Check with your health care provider when you make your appointment to make sure the provider is enrolled with Alaska Medicaid and will accept you or your child as a Medicaid patient.
Arrive on time for your appointment. Call your health care provider’s office if you are unable to make it on time. If you need to cancel, let them know 24 hours before your appointment time. You are responsible for paying for your “no show” appointments.
Show your participant identification card, DKC card, or coupons to your physician or other health care provider each time you receive medical treatment. You must always do this, or you may have to pay for the full cost of your treatment. You may be responsible for a small share of the cost. This is called a copayment.
For your records, you should also ask for a copy of the bill or a receipt. This is proof that you have provided your Medicaid information at the time of service.
Other Medical Insurance or Health Coverage Medicaid is the “payer of last resort.” This means that if you have other health insurance or belong to other programs that can pay a portion of your medical bills, payment will be collected from those sources first. This is called third-party liability (TPL). Medicaid may then pay all or part of the amount that is left.
IMPORTANT! • When you apply for Medicaid, you must indicate if you have any other type of health care insurance or benefits • If you get insurance or medical coverage while you are eligible for Medicaid, you must contact your DPA office immediately and provide the insurance information • If there is a change in your other coverage while you are on Medicaid, you must contact your DPA office immediately • Some important TPL changes include new health insurance because it is a new year, coverage ended, or a dependent is no longer eligible due to age or other circumstance
You are responsible for providing your DPA office with the specific information relating to your insurance coverage. Please include the name, mailing address, and phone number of the insurance, the policy and group numbers and all other information required for medical claims billing.
If you fail to tell your DPA office about your other health care coverage, you may be responsible for part of your medical bill and lose your Medicaid eligibility. Your DPA office can help you determine if you have any other type of health care coverage.
Other sources of health coverage include, but are not limited to the following: • Employment-related health insurance, either the participant’s or that of a family member • Individually purchased health insurance
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• Veterans Administration (VA) benefits • Medicare Parts A, B, C, and D • Tricare/Tricare for Life • Medical support from absent parents • Court judgments or liability settlements for accidents or injuries • Workers’ Compensation • Long-term care insurance • Fisherman’s Fund (for commercial fishermen in Alaska)
The Alaska Health Insurance Premium Payment Program The Alaska Health Insurance Premium Payment (HIPP) program is sponsored by Alaska’s Department of Health and Social Services. HIPP is designed to help Medicaid and Denali KidCare (DKC) participants with the costs associated with health insurance that includes comprehensive medical coverage provided by an employer or COBRA. HIPP membership is completely free for those who qualify and does not affect eligibility for Medicaid and/or DKC.
By qualifying for HIPP, federal law makes it possible for individuals to enroll in employer-sponsored health insurance at any time of the year. No need to wait for open enrollment.
There are three ways to apply for Alaska HIPP benefits: • Apply online at https://www.myakhipp.com • Print a HIPP application from https://www.myakhipp.com • Call toll-free 866.251.4861 to start an application over the telephone
Who is Covered by Alaska Medicaid? Medicaid is an entitlement program that is funded by both federal and state governments. How much each form of government gives in funds changes from time to time. The federal government figures out guidelines that require states to cover certain categories and to provide certain mandatory benefits.
Alaska Medicaid categories include Medicaid Expansion, Family Medicaid, Denali KidCare (DKC), Breast and Cervical Cancer, Long-Term Care, Home and Community-Based Waiver Services, TEFRA, Adult Public Assistance Related Medicaid, and Under 21 Medicaid. These programs assist individuals and families with health care coverage. Each category has unique eligibility rules and guidelines.
Medicaid Expansion Medicaid expansion provides coverage to Alaskans 19 to 64 years old who are not eligible for another type of Medicaid and who have incomes that are less than 138 percent of the federal poverty level.
Family Medicaid Family Medicaid is the primary Medicaid category for financing basic health care for low- income families with dependent children.
Denali KidCare Adults Denali KidCare (DKC) is a program that provides comprehensive health care coverage, including post-partum care of pregnant women who meet income guidelines.
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Children DKC is a program that ensures children and teens of both working and nonworking families have the health care coverage they need. DKC provides comprehensive health care coverage for children and teens through age 18 who meet income guidelines or whose family or parents meet income guidelines.
Breast and Cervical Cancer Program Alaska Medicaid may be available to women who have been screened by a breast and cervical health check (BCHC) provider and found to have either a precancerous condition or cancer of the breast or cervix. The BCHC program provides breast and cervical screening services to women who meet certain income guidelines, who do not have insurance, who cannot meet their insurance deductible or whose insurance does not pay for breast and cervical health screening services. Call 800.410.6266 to find the screening services nearest you or visit the BCHC website at http://dhss.alaska.gov/dph/wcfh/Pages/bchc for more information about this program.
Long-Term Care Participants who need the supervised nursing care services of a certified and licensed skilled nursing facility (SNF), intermediate care facility (ICF), or intermediate care facility for individuals with intellectual and developmental disabilities (IDD) may be eligible for Medicaid. All long-term care services require a service authorization. The participant, authorized representative, hospital, or doctor may work directly with the facility to request admission.
Home and Community-Based Waiver Services Home and community-based waiver (HCBW) services cover the cost of services not otherwise provided for by other Medicaid programs. HCBW may allow for an eligible individual to remain at home and avoid institutionalization in other types of facilities, such as nursing facilities, acute care hospitals, or intermediate care facilities for individuals with intellectual and developmental disabilities.
To be eligible for the HCBW services, a person must meet specific income criteria and be in one of the following population groups: • Aged • Adult physically disabled • Intellectually and developmentally disabled (IDD) • Children with complex medical conditions (CCMC)
TEFRA (Disabled Children at Home) A disabled child who does not qualify for SSI cash assistance due to parental income or resources may be eligible for TEFRA Medicaid based only on the child’s own income and resources.
To be eligible for the TEFRA category, a child must meet specific income criteria and the child must require a level of care provided in an acute care hospital, nursing facility, intermediate care facility for individuals with intellectual and developmental disabilities, or inpatient psychiatric hospital.
Adult Public Assistance Related Medicaid The adult public assistance program (APA) was established in 1989. APA provides financial assistance to needy, aged, blind, and disabled persons. APA helps with self-support or self- care. People who receive APA financial assistance are over age 65 or have severe and long-
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term disabilities that impose mental and physical limitations on their day-to-day functioning. Individuals eligible for APA are also eligible for Medicaid.
Under 21 Medicaid The under 21 Medicaid categories provide comprehensive health care coverage for individuals between age 19 and 21, who meet income and resource guidelines but do not qualify under other Medicaid categories.
Medicaid Behavioral Health Services Behavioral Health Services covered by Alaska Medicaid are described in this section. Behavioral Health services include treatment for everything from depression to substance use disorders (SUDs) to emotional crisis. Behavioral health care can improve the quality of life for individuals with behavioral health and addictive disorders through a broad range services. No one needs to suffer alone or go without help. There are limits to these services and some may require an authorization prior to receiving the service. It is your responsiblity to ask your provider if the service they want you to receive is covered by Medicaid. Please be aware, you are responsible for the payment of any services you receive that are not covered by Medicaid.
While getting care for behavioral health needs, it is important to share this information with your primary medical doctor. This will help you get well rounded care.
Community Behavioral Health Services Services may include screening to determine the presence and severity of behavioral health disorders. Clinic services may include assessments, psychotherapy (individual, group, family), psychological testing, medications management, and crisis intervention services. Rehabilitation services may include assessments, medication administration, day treatment services in a school setting, substance use disorder treatment, and peer support.
Autism Services Services may include behavior identification assessment, behavior identification reassessment, and adaptive behavior treatment (individual, group, family).
Mental Health Physician Clinic Services Services provided by Mental Health Physician Clinics may include psychotherapy, psychiatric assessment, psychological testing and evaluation, neuropsychological testing and evaluation, medication management services, assessment, short-term crisis interventions and screening, and brief intervention services.
1115 Waiver Mental Health Services Services may include home based family treatment, therapeutic treatment homes, assertive community treatment, adult mental health residential treatment, children’s mental health residential treatment, peer-based crisis services, 23 hour crisis stabilization observation, mobile outreach and crisis response services, crisis residential stabilization, intensive case management, community & recovery support services (individual, group), partial hospitalization, intensive outpatient (individual, group), and treatment plan development/review.
1115 Waiver Substance Use Disorder (SUD) Services Services may include community recovery support services (CRSS) for adolescents and adults, partial hospitalization, SUD care coordination services (also known as MAT Care Coordination), 6
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intensive case management for adolescents and adults, peer based crisis services, 23 hour crisis services, mobile outreach and crisis response services, crisis residential stabilization, treatment plan development/review, and American Society of Addiction Medicine (ASAM) levels of care ranging from 1.0 to 4.0.
Services can be provided by an interdisciplinary team of qualified professionals such as; physicians, advanced practice registered nurses, psychologists, licensed clinical social workers, licensed family marital therapists, SUD counselors, behavioral health clinical associates, mental health professional counselors, peer specialists, etc.
Your provider will discuss services with you after they have assessed your individual needs. Your provider may recommend outpatient services, more intensive outpatient services, day treatment services, or treatment in a residential setting. If your provider thinks a different provider might be better for you, they will let you know.
How to get Behavioral Health Services
Mental Health or Substance Use Disorder Services If you or your child needs mental health or SUD services, you can use the Provider Directory at https://alaska.optum.com/. The directory has providers’ addresses, phone numbers, services they provide, languages they speak and information on whether they are taking new clients. To access the directory, choose the “Find a Provider” link. You will be taken to the Live and Work Well website, where you can search for a provider in your community. If you need technical support, choose the “Help” link located toward the bottom of the page.
After you choose a provider, call the provider to schedule your first appointment. If you need help obtaining an appointment with a provider, Optum Case Management can assist you. You can call 800.225.8764, toll-free statewide Monday through Friday between 8:00 a.m. and 6:00 p.m., Alaska Time. After hours, please leave a message and your call will be returned the following business day. You can also visit our website at https://alaska.optum.com/. You may also email the helpline staff at [email protected].
Emergency Services Alaska Medicaid covers immediate care that is necessary when a sudden, unexpected occurrence creates an emergency. An emergency exists when you think your life is in danger, when you believe you might harm yourself or others, or when your safety or others’ safety is at risk.
Inpatient Psychiatric Hospital and Residential Psychiatric Treatment Services Alaska Medicaid requires a service authorization for all psychiatric admissions and continued stays at both in-state and out-of-state facilities. An evaluation, a proof of need for inpatient psychiatric services, and a plan of care must be completed and sent to Optum Alaska Medicaid for review.
• Inpatient psychiatric hospital services – Medicaid coverage is limited to people with acute psychiatric needs who are either under the age of 21 or over the age of 65 • General inpatient hospital – coverage is available to all eligible participants with acute psychiatric needs • Residential psychiatric treatment centers (RPTC) – coverage is limited to 7
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people up to age 21. RPTCs provide residential care and treatment of mental, emotional, or behavioral disorders
Travel for Non-Emergency Services If you have any questions about how to use Medicaid travel benefits please call the Medicaid Participant Helpline at 800.770.5650, option 2.
Medicaid Participant Rights and Responsibilities
Rights as a Patient As a patient, you have the right to: • Get information on your Medicaid benefits that is easily understood • Get written information on your Medicaid benefits in a language and format that is easily understood • Be treated with respect and dignity • Have your privacy protected • Get information on other types of treatment in a way that is easily understood • Take part in treatment decisions regarding your behavioral health care, including the right to refuse treatment • Be free from restraint or seclusion if it is used these ways: • To coerce (force) or discipline • As a reaction (to retaliate) or for convenience • As specified in federal regulations on the use of restraint and seclusion • Get a copy of your medical record(s). You can also ask that they be amended or corrected when allowed by federal law • Get behavioral health services in the amount you need and when you need them • Be free to use your rights at any time and not be treated badly by Alaska Medicaid, Optum, or by your Provider if you do
You also have the right to be treated fairly and to get behavioral health care regardless of your race, color, national origin, age, disability, sex, sexual orientation, or gender identity.
Responsibilities as a Patient As a patient, you are responsible to: • Keep your appointments and be on time • If you need to cancel an appointment, call the provider 24 hours in advance • Be involved in your treatment plan and care • Tell Optum and your Medicaid eligibility worker of changes in your address, phone number or insurance • Complete any surveys that providers give you • Respect the property, comfort and confidentiality of patients and staff • Notify your treatment provider when you want to stop getting services
Managing Your Care and How Medicaid Billing Works
Proof of Eligibility You must show your Medicaid identification card to your health care provider before receiving services. Your provider will send the bill directly to Alaska Medicaid for payment. 8
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Your health care provider may make a copy of your Medicaid identification card or coupon. If you did not receive your card or coupons you may call your Division of Public Assistance office.
Medicaid regulations do not allow for reimbursement to participants if they pay for their own services.
Your Copayment Participants may be required to share the cost for some services that they receive. This amount is called a “copayment”, and may include: • $50 a day up to a maximum of $200 per discharge for inpatient hospital services • $3 per day for physician services • 5 percent of allowable charges for outpatient hospital services (except emergency services) • $.50 for each prescription that is filled or refilled with a payment for service of $50 or less, or $3.50 for each prescription drug that is filled or refilled, with a payment for service of greater than $50
You will be asked to pay the copayment amount directly to your health care provider when you receive services. If you cannot pay at the time services are provided, you will still receive services. Your provider will bill you for the copay amount. If you do not pay your copayments when you are billed, your provider may refuse to see you for future appointments.
Copayment is NOT required for: • Children under the age 18 • Pregnant women • Tribal health services provided to an individual who is American Indian or Alaska Native • Services provided to an individual who is eligible for both Medicare and Medicaid if Medicare is the primary payer for the service • People in nursing homes • Family planning services and supplies • Emergency services • Hospice care • CAMA participants
If you are pregnant, notify your Division of Public Assistance office right away. Your coupons will be changed to show you are pregnant so that you will not be charged a copayment.
If You Receive a Bill In the event you receive a medical bill for an amount other than your copayment, you should first contact the provider at the phone number on the bill or statement to confirm that the provider has your correct participant information in order to bill Alaska Medicaid. A participant may also contact the Medicaid Participant Helpline to verify if Alaska Medicaid paid the claim.
Alaska Medicaid does not reimburse for non-covered services, including “no-show” or cancellation fees charged by a provider. Please keep your scheduled appointment; however, if you are unable to do so, notify your provider as soon as you know that you must cancel or reschedule.
If You Receive a Payment For Services Paid by Medicaid In the event you receive a payment from any other source of health insurance, you must first 9
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contact your provider. If the provider confirms that Medicaid has already paid your medical bill, you must contact the Division of Health Care Services at 907.334.2400 and ask to speak with someone in the Accounting and Recovery Unit for guidance on how to refund Medicaid. If you fail to repay or refund money you have received for services paid by Medicaid, the state will take action that may affect your eligibility for Medicaid.
Retroactive or Backdated Eligibility If you are approved for retroactive or backdated eligibility, you will receive a notice titled “Retroactive Medicaid Approved” or “Backdated Medicaid Approved” from your Public Assistance or Denali KidCare (DKC) office. Provide copies of this notice to all of the providers you received services from during the period covered by your retroactive, backdated eligibility. If your provider accepts your retroactive or backdated eligibility status, you are responsible only for non-covered services and copayment amounts. You may contact the Medicaid Participant Helpline with questions about your bill. If your provider does not accept your retroactive or backdated coverage, or you do not provide a copy of the notice to your provider, you will be responsible for the service(s).
Service Authorization Some services covered by Medicaid require a service authorization before they are received. Only your provider can make a request for a service authorization on your behalf. Please do not call the Alaska Medicaid Participant Helpline to obtain this authorization.
The following is a list of some of the most common services that will require your provider to obtain a service authorization: • Travel, lodging, and meals • Some prescription drugs • Hospitalization
Medicaid Renewal Information To keep your benefits current, complete and return your renewal application by the requested date. That date is the fifth of the month your benefits are to end. If you turn in your renewal application on time and you are found eligible to continue receiving benefits, there will be no gap in your coverage.
If you turn in your renewal application late, your Public Assistance office may not have time to process your renewal application before your benefit eligibility coverage period ends. This means your Medicaid benefits will be delayed. If you need to use benefits before you receive your card, contact your Public Assistance office or Denali KidCare (DKC). Statewide offices are listed in the back of this book. Your coupon can be issued by fax directly to your health care provider.
How You Could Lose Your Medicaid Eligibility Some of the reasons you could lose your Alaska Medicaid eligibility are: • You lose your status as a resident of Alaska • Your income or assets increase • Your household composition changes • You lose your disability status • You fail to cooperate with the Child Support Enforcement Division (CSED) • Your Public Assistance office loses contact with you
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• Your age makes you ineligible for certain Medicaid categories • You are untruthful about your Medicaid application or you knowingly break Medicaid rules • You fail to provide to Medicaid any information about insurance and other health coverage that is available to you • You or your legal representative fails to fully cooperate and repay Medicaid from financial settlements, judgments, or awards obtained from a responsible third party for services that were paid by Medicaid • You do not send in your renewal application on time
If you are unsure about your eligibility or what may cause you to become ineligible, contact your Public Assistance office.
Fraud, Waste and Abuse
Fraud Fraud includes using someone else’s medical benefits for your health care services, using someone else’s Social Security number to qualify for government assistance or providers billing for services that did not occur.
Waste Waste is the planned use, throwing away or spending of health care or government resources in an unwise and wrong manner.
Abuse Abuse is the planned misuse of health care or government resources. Such as requesting and getting medications you do not need to use or a provider billing for services that did not occur.
If you think someone is using your Medicaid information or committing fraud, waste or abuse, please call the Optum Alaska Medicaid helpline.
Complaints If you have a complaint about anything, you may call Optum Alaska Medicaid helpline for assistance. Examples of complaints include concerns about the services given to you, rudeness of a provider, a provider not respecting your rights or suspicious behavior. You can also file a complaint if you’ve received a bill for a service covered by Alaska Medicaid.
You, your legally authorized representative or your provider (with your permission) can file a complaint.
Complaints received are strictly confidential. You may report anonymously, although we prefer to have a way to contact you in case, we need more information. If you provide your personal contact information, please be assured that it will be kept confidential.
There is no deadline for filing a complaint. You may file a complaint at any time.
How do I File a Complaint? Call the Optum Alaska Medicaid helpline or use the online complaint form. Submit your complaint by fax to 855.508.9353, attention Complaints, or by mail to:
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Mail: Optum Alaska Attn: Appeals & Complaints 205 East Benson Blvd. Suite 100 Anchorage, Alaska 99503
Adverse Benefit Determinations Adverse Benefit Determinations are when: • Optum denies (turns down) or approves fewer services than you wanted • Optum denies payment for a service to which you might be responsible for payment • Your provider reduces or stops a service previously approved. If you agree with the change, it is not an action. It is only an action if you tell us you don’t want the change
We will send you a letter called a Notice of Adverse Benefit Determination. You will have the right to request a fair hearing if you disagree with our action.
Fair Hearings
What is a Fair Hearing? If you disagree with a decision or action that was made by Alaska Medicaid, you have the right to ask for a fair hearing. A fair hearing is an administrative procedure in which an impartial hearing officer decides if the decision or action you disagree with was appropriate.
The following are examples of decisions or actions that may result in a fair hearing request: • Denied application for Medicaid, home and community-based waiver services, or other benefits • Terminated, reduced, or changed benefits • Denied coverage for a specific medical service • Denied or partially denied service authorization or claim
How to Request a Fair Hearing Requests for Medicaid fair hearings must be made in writing. A request for a fair hearing may be submitted by you or your representative.
If you disagree with a decision that was made about your Medicaid application or recertification, or if your Medicaid benefits were terminated, submit your request for a fair hearing to the Division of Public Assistance (DPA). The notice you received from DPA explains how and where to submit your request. DPA office addresses and telephone numbers are also included in this booklet.
If your denial is related to medical services or billing, submit your fair hearing request by fax to 907.644.8126, attention Fair Hearings, by email to [email protected] or by mail to:
Mail: Conduent State Healthcare Attn: Fair Hearings PO Box 240808 Anchorage, AK 99524
Privacy and Confidentiality Your personal health information is protected by state and federal regulations, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA provides you 12
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BH3459_062021 United Behavioral Health operating under the brand Optum with basic rights with respect to accessing and protecting your own individual health information. To find out more about how the state is safeguarding your personal health information, view the DHSS website at: http://dhss.alaska.gov/dhcs/Pages/hipaa. You may also view the DHSS privacy notice at: http://dhss.alaska.gov/dhcs/Documents/PDF/HIPAA/HIPAA_Privacy_Notice.pdf.
How to Find a Provider You can to go to the Optum website at https://alaska.optum.com/ and on the left side of any page you will see Find a Medicaid Provider Search. Click on this and you will be able to use the search tool to find a provider in your area.
You may call Optum Alaska Medicaid helpline to request a paper copy of the provider directory or ask any questions you may have about providers in your area.
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OPTUM ALASKA MEDICAID PARTICIPANT INFORMATION HELPLINE 800.225.8764
BH3459_062021 United Behavioral Health operating under the brand Optum
Medicaid Eligibility Codes and Coverage Categories
There are many types of Alaska Medicaid and each type has an assigned eligibility code. The eligibility code indicates to your provider what type of services you are eligible to receive through Medicaid. Listed below in the chart is a brief description of the codes printed on a Medicaid card or coupon that are eligible for Behavioral Health Services. The benefit information is only a brief summary and is not intended to be a complete description of your benefits. For more information please contact the Medicaid Participant Helpline at 800.770.5650, option 2.
Eligibility Code and Eligibility Code and Description Description Medicaid for Pregnant Four months of Medicaid for
11 women participants otherwise ineligible
52 due to earned income.
Family Medicaid or Adult Medicaid-only for disabled 20 Public Assistance (APA) 54 child receiving SSI related Medicaid Institutional Long-Term APA/QMB – full Medicaid 24 Care (LTC) Medicaid 69 plus QMB. Waiver for adults with Intellectual & developmental 30 70 physical & disability (IDD)–waiver 31 developmental 71 disabilities Adults with physical and Intellectual & developmental
developmental disabilities– disability (IDD)–waiver, APA 34 waiver APA/QMB 74 and receives Medicare 40 Older or disabled adult with 80 Medically Complex 41 waiver and Medicaid 81 Children–waiver Older or disabled adult Individualized Supports with waiver Medicaid, 91 waiver – Special LTC 44 adult public assistance and QMB Medicaid for children Individualized Supports 92 50 under age 21 who are not waiver in state custody Medicaid for children under Individualized Supports age 21 who are in state 93 waiver – 51 custody, including Title IV- Pregnant Woman E foster care Four months of Medicaid Individualized Supports for participants otherwise 94 waiver – 52 ineligible due to earned APA/QMB eligible income. 14
OPTUM ALASKA MEDICAID PARTICIPANT INFORMATION HELPLINE 800.225.8764
BH3459_062021 United Behavioral Health operating under the brand Optum
Helpful Websites and Phone Numbers
Advisory Board on Alcoholism and Drug Abuse http://dhss.alaska.gov/abada
Alaska Commission on Aging http://dhss.alaska.gov/acoa
Alaska Mental Health Board http://dhss.alaska.gov/amhb
Division of Behavioral Health http://dhss.alaska.gov/dbh Toll-free Juneau: 800.465.4828 In Juneau: 907.465.3370 Toll-free Anchorage: 800.770.3930 In Anchorage: 907.269.3600 In Fairbanks: 907.451.5042
Division of Health Care Services http://dhss.alaska.gov/dhcs In Anchorage: 907.334.2400
Division of Public Assistance http://dhss.alaska.gov/dpa
Division of Public Health http://dhss.alaska.gov/dph
Division of Senior and Disability Services http://dhss.alaska.gov/dsds Toll-free Anchorage: 800.478.9996 In Anchorage: 907.269.3666 Toll-free Fairbanks: 800.770.1672 In Fairbanks: 907.451.5045 Toll-free Juneau: 866.465.3165 In Juneau: 907.465.3372
Early Screening (EPSDT) Program Travel Toll-free statewide: 888.276.0606 In Anchorage: 907.269.4575 Note: The Early Screening Program provides assistance for pregnant women and children to attend medical and WIC appointments.
Governor’s Council on Disabilities and Special Education http://dhss.alaska.gov/gcdse Toll-free: 888.269.8990 In Anchorage: 907.269.8990
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OPTUM ALASKA MEDICAID PARTICIPANT INFORMATION HELPLINE 800.225.8764
BH3459_062021 United Behavioral Health operating under the brand Optum Home and Community-Based Service Waiver http://dhss.alaska.gov/dsds/Pages/hcb/hcbwaivers.aspx Toll-free: 800.478.9996 In Anchorage: 907.269.3666
IDD Waiver Unit and Services http://dhss.alaska.gov/dsds/Pages/dd Toll-free: 800.478.9996 In Anchorage: 907.269.3666
Medicaid Travel Offices: Alaska Medicaid Travel Office https://us.travelctm.com/medicaid/ Toll-free: 800.514.7123 8:30 a.m. – 5:30 p.m., Mon – Sat; 12:00 p.m. – 4:00 p.m., Sun
ANTHC Travel Management Office Toll-free: 866.824.8140, option 1 In Anchorage: 907.729.7720, option 1 8:30 a.m. – 5:30 p.m., Mon – Sun
TCC Patient Travel Toll-free: 800.478.6682, ext. 3711 In Anchorage: 907.451.6682, ext. 3711 8:00 a.m. – 5:00 p.m., Mon – Fri; 10:00 a.m. – 2:00 p.m., Sat
YKHC Medicaid Patient Travel Toll-free: 855.543.6625 In Anchorage: 907.543.6625 8:30 a.m. – 5:30 p.m., Mon – Sun
Note: For air travel only after service authorization by your provider
Medicare (official U.S. Government website) www.medicare.gov Toll-free: 800.MEDICARE (800.633.4227)
Medicare Information Office http://dhss.alaska.gov/dsds/Pages/medicare Toll-free statewide: 800.478.6065 statewide In Anchorage: 907.269.3680
Optum Alaska https://alaska.optum.com/ Toll-free statewide: 800.225.8764
Personal Care Assistance Program http://dhss.alaska.gov/dsds/Pages/pca Toll-free: 800.478.9996 In Anchorage: 907.269.3666
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OPTUM ALASKA MEDICAID PARTICIPANT INFORMATION HELPLINE 800.225.8764
BH3459_062021 United Behavioral Health operating under the brand Optum
WIC (Women, Infants, and Children) http://dhss.alaska.gov/dpa/Pages/nutri/wic
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OPTUM ALASKA MEDICAID PARTICIPANT INFORMATION HELPLINE 800.225.8764
BH3459_062021 United Behavioral Health operating under the brand Optum
Public Assistance District and Field Offices
The statewide centralized email address is [email protected]. Emails will be filtered out to the field offices by DPA staff.
Anchorage Kenai 3901 Old Seward Hwy, Suite 131 11312 Kenai Spur Hwy., Suite 2 Anchorage, AK 99503 Kenai, AK 99611 Phone: 800.478.7778 Phone: 800.478.7778 Fax: 907.269.6520 Fax: 907.283.6619 or 888.248.6619 Bethel Ketchikan 460 Ridgecrest Dr., Suite 121 2030 Sea Level Drive, Suite 301 Mailing: P.O. Box 365 Ketchikan, AK 99901 Bethel, AK 99559 Phone: 800.478.7778 Phone: 800.478.7778 Fax: 907.543.2650 Fax: 907.247.2135
Fairbanks Kodiak 675 7th Ave., Station E 211 Mission Rd., Suite 101 Fairbanks, AK 99701 Kodiak, AK 99615 Phone: 800.478.7778 Phone: 800.478.7778 Fax: 907.451.2923 Fax: 907.486.3116 or 888.281.3116
Heating Assistance Program Office Long Term Care October 1 through April 30 3901 Old Seward Highway, Suite 131 10002 Glacier Hwy, Suite 200 Anchorage, AK 99503 Juneau, AK 99801 Phone: 907.269.8950 or 800.478.4372 Contact your local DPA office. Fax: 907.269.5608 or 855.869.5608 www.heatinghelp.alaska.gov Nome Homer 214 E. Front Street 3670 Lake Street, Suite 200 Mailing: P.O. Box 2110 Homer, AK 99603 Nome, AK 99762 Phone: 800.478.7778 Phone: 800.478.7778 Fax: 907.235.6176 Fax: 907.443.2307 or 888.574.2307
Juneau Sitka 10002 Glacier Hwy., Suite 201 304 Lake Street, Suite 101 Mailing: P.O. Box 110642 Sitka, AK 99835 Juneau, AK 99811-0642 Phone: 800.478.7778 Phone: 800.478.7778 Fax: 907.747.8224 Fax: 907.465.4657 Wasilla 855 W. Commercial Dr. Wasilla, AK 99654 Phone: 800.478.7778 Fax: 907.373.1136 or 877.357.2538
Please visit http://dhss.alaska.gov/dpa/#offices for the most up-to-date list. 18
OPTUM ALASKA MEDICAID PARTICIPANT INFORMATION HELPLINE 800.225.8764
BH3459_062021 United Behavioral Health operating under the brand Optum